Mindspace Peer Support Registration Form
Personal Details
Title
Please select...
Mr.
Ms.
Mrs.
First Name
Last Name
Date of Birth (DD/MM/YYYY)
Gender
Please select...
Male
Female
Other
Prefer not to say
Flat/House No. & Street Name
Town / City
Postcode
Email
Mobile Phone
Home Phone
Preferred Phone
Please select...
Mobile
Home
Can we leave a message on this number?
Please select...
Yes
No
Additional Information
Why are you interested in Peer Support?
What do you hope to gain from Peer Support?
Do you have a disability or any special access requirements?
How did you hear about us?
Employment Status
Please select...
Employed Full Time
Employed Part Time
Student
Retired
Sickness / Disability Benefit
Unemployed
Carer
Voluntary Worker
Migrant Worker
Other
Not Specified
What days/times are you available for peer support
Mondays 9am-11am
Mondays 11am-3pm
Tuesdays 9am-11am
Tuesdays 11am-3pm
Wednesdays 9am-11am
Wednesdays 11am-3pm
Thursdays 9am-11am
Thursdays 11am-3pm
Thursdays 3pm-5pm
Fridays 9am-11am
Fridays 11am-3pm
Fridays 3pm-5pm
Emergency Contact Details
Contact Name
Contact Number
Data Protection Statement
Your personal information will be processed and kept secure in accordance with Mindspace Limited Privacy Policy(Statement and the full policy are available on our website) and in line with GDPR (2018) regulations. This includes processing your data for registration and your anonymised collective data for reporting and funding purposes. We will not pass your information to third parties without your permission. However, if we are concerned about your safety or the safety of others, and where
required
by law, we will give your details to appropriate third parties.
Do you consent to us keeping your details for the purposes outlined above?
Yes
Date
In addition and separately from using personal information as described above, we would like to contact you from time to time with details of other courses or events we are running. Are you happy to receive this communication?
Please select...
Yes
No
How would you like us to communicate with you?
Email
Text Message
Telephone
Contact Information